S 1844 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CLPERPINO BUILDING.ELECTRICAL PES11 NO, 1844
BUILDING DIVISION APPLICATIONMERMIT DING PRNG-MECE TIFIC l\J
IIUILUINC 1'ROJRL'f IDENTIFICATION
BUILDING ADDRESS: SANITARY No APPLICATION SUBMITTAL DATE
/3-73 El pp,.f ti" G uP6R r TMJ o CA •4 s vis 7-2 -
OWNER'SNANi PHONE: CONTRACTORS NAME: LIC NO:
N/ ="YA IC Ooh/A k4 t i.lzs NIC CON'1'HOLp
. ARCHITECI'VENGINEER: I. NO: ADDRESS: ❑
CON'1'ACr: l/ipNil: BUILDING PERMIT INFO
y " ❑ Consultant Feu Paid by Applicant(Initial) BLDG / ELECT PLUMB NIE❑CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECPRIC PERMIT FEE L^�'/
I hereby anion tam 1 am licensed under pmvisions of Clap,er 9(commencing JOB DESCRIPTION
ray win,Sectini 700alor])iskinn 3o1 he Businessland Pn colors Cole,slid.],,license is RESIDENTIAL:
WOO PERMITISSUANCE
C-F- infull Class
ellen. ❑SFDWI. [I KITCHEN REMODEL
Q UO License Class Lic'N APPLIANCES-RESIDENTIAL ADD[HON [I PLUMBING RE-PIPE
yZW Dae Contractor
Dy ARCHITECT' PANELS DECLARATION PANELS ❑MULTI"UNIT [I STRUCTURAL
F u 1 understandpla
d my ns shall he used as public rrecordsMODIPICACION
OZy UPTO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
[s.�F.LLI Licensed Professional 201.1000AMPS IMPRO :MENT SWIMMING POOLS
O��j OWNER-13111LDER DECLARATION OVER 1000AMP$ H REMODEUREPAIR ❑DEMOLITION
-0. 6 1 hereby affirm that I am exempt from the Coincident x License Law for the
fa'O 0.U following reason(Section 7031.5,Business and Professions Code:Any city lir county SIGNS ELECTRICAL El OTHIiR
YI a W F which requires a permit to conswe6 alter,improve.demolish,or repair any sm,mure
photon its issuance,alsorequims meapplicam for.mch penninofile esigaedsmtemem SPECIAI:CIRCUIT/MISC.
d� mal he is licuneed pursuant o the provisions ofthcCon,melor's License Law(Chapler1)
X00 (commencing with Section 70WbcfDivirion3 ofthe Businexsand Professions Code)or TEMP.MITER OR POLE INST. COMMERCIAL:
e k n ty that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Seen 17031.5 hynnyupplicnm to r a Nrouir atbjecs"mcapplicam tw,civil penalty of POWER DEVICES ❑'1'PNAN'17 ❑PGQD SERVICE
t more than five hundred dollars($500). IMPROVEMENT
=0O1,us owearof the pmpety.many employees with wages as then.-le compensation, SWIMMING POOL ELI[. IC
p. will do thework,and me,rm,numis of intended or nlTered for mle(Set.9044,Business ❑OTHER
W and Pr..fessinna Code:The Contractors License law does not apply to an or,of OUTI.I.I S-SWITC 19
1'URP_S
0'3 propeny who builds or improves thereon,:rad who does such work 11 travel r or through
his own employes,provided that such improvemenrs arc not intended or offered lot NEW RUSIDIifs r1AI.Fox SQ IT,
sale.If,howeem the building m impmvemmn is sold within one year of mmpledom,the SQ.IT.MOOR A REA S/SQ.1--n
owner—thee Ider wl11 hmethe huNon of proving,hal he did not build or halne,c for No
11 1.c.
I,as oof the propery,am elu
xcsively combining with rn
licensed cmnnm nm TOTAL:
wner
,nmuuat the project(See.9144,Rusiness:md Profcxsioms Code:)The Candecmr's Li.
live law does not apply to on owner of property who builds or improves,hereon.unit QTY. PLUMBING PERMIT FEE
who cordeels for soot pmjrnb all a mnwetor(s)Ilcemul th rxuum en the Comwcun's
License law. PERMIT ISSUANCE
❑E.mn exempt ler c. .,B&1'C for,his reason
A L'1'ER-DRAIN&VENT'-WA'T'ER(EA) VALUATION
Ow Date
• tK' ,COMPENSATION DECLARATION BACK PLOW PROTECT'.DEVICE O Cot'
Iherehy anoint de rally ol'perjnry one of the billowing declarations: ¢/
I aavenedwill meimaina .enifmvm of Cnnsenuoself-Ensure for Wnrkcrs Compete DRAINS-FLOOR,ROOF,AREA,CON). STORIES TV PH CONSTR UCI'ION
warns,m provided for by Section 394 or the Labor Code,III,the petfomumce of the
work for which this pem,it is Issued FIKTDRES-PER TRAP
❑1 have and will maimain Worker's Compe came Imsumme,as required by Station
9981 nrthe Labor Gila,for the perfnrmmdccof the work for which this pursuit is l"mad. GAS-IM.SYS'I'EM-I INCA OGTLE?'TS OCCGROUP MIN
My Worker'"Compensation Insurance carder and Policy number ore:
Cartier: Policy NO.: GAS-EA.SYS'l FM OVER 4(IIA)
CBR'I'I pICNIE OF EKEM EYI'ION FROM WORKERS' GREASEENDUSTRL WASTE INTERCEPTOR
COMPENSM ION INSURANCE BUILDING DIVISION ITHS
(This senior need net he eomplded if,he Penni,is Rood hmulreddollnrsg100) GIIHASI'I'RAP
lir
less) PLANCHECK FEL>
Icenify tha,imhe performance of the work ftn which,his permit is issuta l.hall SEWER-SANITARY-STORM EA.200 FP.
not employ any Nunn in anynmmncrso as to bee lrsuhlecl to the Workers'ComNm. ENERGY 113E
z cation Laws of California.Date WATER HEATER WNENWELECTR
0 Applicant GRADING PEE.
w~N.x NOTICE TO APPLICANT:II;after making this Certificate of Exchudem,you should WATER SYSTEM/PREM ING
become subject to the Workers Comperoation previsions of the Labor Cale,you must SOILS FEE
Iry
LaIJ fonhwint cmmply with such provisinnn lir this permit shall let decmnl revoked. WR'I'ER SERVICE
aQ
0 z CONSTRUCTION LENDING AGENCY NEW RIiSIDENTIAL I'LMIi. SQ.fT, PAID Qam <cceipt p
U O Inereny arrmt roto mete iaaconxtmernr binding aaancy fon deperrmman«m
the work for which this permit is issued(Sec.3097,C .C.)
R" Landers Name TOTAL:
(U lender's Address. (TIAL.
fy 1 cenify that I have mad Nis application a d ante that]he abwc infommtion is 2-J 0BUILDING FHE
h mren.l agree mcomply aim nil city and entmty onlimmees and scent laws rclatingto QTY. MHCHANICALPFRMIT FEE fi�es..
fJZ building construction,and hereby carbonize representatives of this city to enter upon the View FEE Q
above-mentioned property for inspection purposes PFRMG ISSUANCE
(We)agrca to save,indemnify send keep harmless oho City of Cupenimr again", s_LECI RI
AP
I Iiabildies.jadgmenls,nds and expensexwhichmey oanywzyaecom a gain,Haid City ALTER OR ADDTO MUCH,
in compliance of the gramine of this permit. P GILE `-J T
APPLICANT'UNDEKSTANUS AND WILL COMPLY WITH AL1.NON-POINT AIN HANDLING UND('10 I0,000CFM) CPIANICAIa,FEE
SOURCE REGULATIONS.
Alit HAN DUNG UNIT(OVER 10.000 CPM) CONS'TRI)CI'ION TAX
Signature of AppliranJCommetor Date EXHAUST HOOD(WIGGED 'Hsi USING MITIGATION FII:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcediam,are or handle hazardous material HEAPING UNIT('101(IB,(ga)BT U)
as defined by the CuNninn Municipal Code,Chapter 9,12,.nd the health and Safety
Cade,Section 25532nd? HEATING UNIT'(OVER blib,not BTU)
❑Yes ❑NoV13NTILA'CION PAN(SINGLE RESIDE PAID
Date Receipt M
Will the applicant or al;i building by he B use equipment or devices which
emit bar rdous eir conwmmams as defined by,he Bay Arco Air Quality klunagemen, R(IILER-EOMI'pHi'OR IfD,fKXI BTU) TO"AL:
Diou"? BOILER-COMP(OVER 100.4)BTU) 4001
C]Yew E]No
I have real the h:moNons materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
forma Health&Safety Code,Seetiom 25505.25533 and 25534.1 undersand that Bible NEW RESIDENTIAL MECH. SQ.IT.
boiling does ran comenly have a tm,ent.than it iamyresicr.ibdhy orninymeoecupam 7�Z
of me requlremems which must he met prions issuance of a Cmif ate of 1Rcupancy. O
Owocnn sarbnimd.,cut Date TOl'AL: ISSUED BY. 7
OFFICE